Provider Demographics
NPI:1205914710
Name:ROSEBANK PHARMACY LLC
Entity type:Organization
Organization Name:ROSEBANK PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:BS, MPA
Authorized Official - Phone:917-213-6931
Mailing Address - Street 1:500 TOMPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1743
Mailing Address - Country:US
Mailing Address - Phone:718-727-0426
Mailing Address - Fax:718-816-1803
Practice Address - Street 1:500 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1743
Practice Address - Country:US
Practice Address - Phone:718-727-0426
Practice Address - Fax:718-816-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0324023336C0003X
NY12030NY3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04128465Medicaid
2144358OtherPK
2144358OtherPK